Every finding on record at Columbus Hospice, Inc.

Based on observation and staff interviews it was determined the facility failed to verify self-closing doors are kept closed.This affects residents and staff in the near the employee breakroom. --- The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that the self-closing door to the employee break room was propped open with a wedge.These findings were confirmed by Staff M at the time of discovery.Reference:   2012 NFPA 101, 19.3.2.1.3, 19.2.2.2.7

Based on observation and staff interviews it was determined the facility failed to maintain the exit signsThis affects residents and staff in the entire facility. --- The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that an exit sign in the main corridor failed to function under back-up battery when tested.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, 19.2.10.1, 7.10.5.1

Based on observation and staff interviews it was determined the facility failed to maintain the attic access door in the closed position.This affects residents and staff in the entire facility. --- The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that the attic access door was left in the open position in the janitor room.  In the event of fire, smoke and heat would have spread into the attic.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, Chapter 19, Section 19.3.1

Based on observation and staff interviews it was determined the facility failed to properly maintain the safety precautions surrounding the fire alarm breaker.This affects residents and staff in the entire facility. --- The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that the fire alarm circuit breaker was not identified in red and did not include a breaker lock to prevent the disconnection of power to the fire alarm system.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, 19.5.1.1, 9.1.2 and  2011 NFPA 70, 760.41(A)(B), 2012 NFPA 101, 19.3.4.1, 9.6.1.3, 2010 NFPA 72, 10.5.5.2.1 through 10.5.5.2.4

Based on a review of facility records and staff interviews it was determined the facility failed to conduct fire alarm system sensitivity testing.This affects residents and staff in the entire facility. --- The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that a record of fire alarm sensitivity testing was not available.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, 19.3.4.1, 9.6.1.3, 2010 NFPA 72, 14.4.5.3.1, 14.4.5.3.2

Based on observation and staff interviews it was determined the facility failed to maintain the sprinkler system.This affects residents and staff in the entire facility. --- The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that the sprinkler system gauge was dated 2019.  Gauges must be replaced after 5 years. These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, 19.1.1.1.3, 19.1.6.1, 19.3.5.4, 9.7.1, 2011 NFPA 25, 5.3.2.1

Based on observation and staff interviews it was determined the facility failed to maintain access to the electrical panel and protect electrical wires on the panel from exposure.This affects residents and staff in the entire facility. --- The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that access to the electrical panels was blocked by a portable cart.  The electrical panel was missing a metal plate exposing electrical wires.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 110.26, Article 408.7

Based on observation and staff interviews it was determined the facility failed to provide emergency lighting for the generator.This affects residents and staff in the entire facility. --- The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that the electrical generator was not equipped with a battery powered emergency light.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, 19.5.1.1, 9.1.3.1, 2010 NFPA 110, 7.3.1, 7.3.2, 7.3.3

Based on observation and staff interviews it was determined the facility failed to maintain safe power strip usage.This affects residents and staff in the in or near the breakroom. --- The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that a vending machine was plugged into a power strip located on the floor of the breakroom.  The vending machine should be plugged directly into the wall.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 99, Chapter 10, Sections 10.4.2.1 through 10.4.2.3 and CMS S&C letter 14-46-LSC

Based on clinical record review, staff interview, and review of policy titled “Bereavement Protocol,” it was determined the interdisciplinary group failed to ensure that the initial bereavement assessments were completed for three patients (P) (P#1, P#12, P#21) of 25 sampled patients. --- Findings include: Review of policy titled “Bereavement Protocol,” revised February 7, 2025, reveals the following:Procedures:1. A Pre-Bereavement Assessment will be completed and documented by the team Social Worker during the comprehensive initial assessment of the patient. 1. Review of the clinical record reveals P#1 was admitted on 6/20/2023.The clinical record failed to indicate that the initial bereavement assessment was completed and failed to reveal documentation regarding the delay in completing the assessment. 2. Review of the clinical record reveals P#12 was admitted on 11/7/2024.The clinical record failed to indicate that the initial bereavement assessment was completed and failed to reveal documentation regarding the delay in completing the assessment. 3. Review of the clinical record for reveals P#21 was admitted on 2/8/2024.The clinical record failed to indicate that the initial bereavement assessment was completed and failed to reveal documentation regarding the delay in completing the assessment. On 4/29/2025 at 1:58 p.m., an interview was conducted with the compliance officer, who said that the initial bereavement assessment was not done. The compliance officer also confirmed that all available documentation for the clinical record has been provided.

Based on review of narcotic verification sheets, review of policy titled “Medication Administration and Management,” and staff interview, it was determined that the nurse failed to sign shift counts of the narcotic medications in the IPU (in patient unit). --- The findings include:Review of policy titled “Medication Administration and Management,” revised November 20, 2024, reveals the following:Medication Administration in the Inpatient Unit:2- A full count of all controlled substances is done at each shift change. Review of the "Narcotic Verification Sheet," in the IPU medication room revealed that the signatures of nurses working in the IPU were missing in the narcotic medications count sheets. Missed shift signatures reveal the following: •    2/4/25 7 a.m., outgoing nurse, and 7 p.m., incoming nurse •    2/5/25: 7 a.m., outgoing and 7 p.m., outgoing signatures were blank •    2/8/25: 7 p.m., outgoing signature page was blank •    2/14/25: 7 a.m., outgoing signature page was blank•    2/19/25: 7 p.m., incoming signature page was blank •    2/20/25: 7 a.m., outgoing signature page was blank •    2/22/25: 7 a.m., outgoing signature page was blank •    2/27/25: 7 a.m., outgoing signature page was blank •    2/28/25: 7 p.m., outgoing signature page was blank•    3/3/25: 7 p.m., outgoing signature page was blank •    3/5/25: 7 a.m., outgoing signature page was blank •    3/9/25: 7 p.m., outgoing signature page was blank •    3/10/25: 7 a.m., incoming signature page was blank, 7 p.m., outgoing signature page was blank •    3/12/25: 7 p.m., outgoing signature page was blank •    3/13/25: 7 a.m., incoming signature page was blank •    3/14/25: 7 p.m., outgoing signature page was blank •    3/16/25: 7 p.m., outgoing signature page was blank •    3/18/25: 7 p.m., incoming signature page was blank •    3/19/25: 7 a.m., outgoing signature page was blank•    3/20/25: 7 a.m., outgoing signature page was blank, 7 p.m., outgoing signature page was blank •    3/21/25: 7 p.m., outgoing signature page was blank •    3/23/25: 7 p.m., outgoing signature page was blank•    4/1/25: 7 a.m., outgoing signature page was blank •    4/3/25: 7 p.m., outgoing signature page was blank •    4/9/25: 7 a.m., outgoing signature page was blank •    4/17/25: 7 p.m., incoming signature page was blank •    4/18/25: 7 a.m., outgoing signature page was blank •    4/22/25: 7 p.m., incoming signature page was blank •    4/23/25: 7 a.m., outgoing signature page was blank On 4/28/25 at 11:35 a.m., an interview was conducted with Hospice House Director (HHD), who said that she did not know why the nurses were not signing the narcotic counts sheets at IPU medication room. HHD also said that the nurses involved were not available for interview.

Based on clinical record reviews, and staff interviews, it was determined the interdisciplinary group (IDG) failed to ensure comprehensive assessments/plan of care were updated to include evaluation and documentation of the patient's response to wound care, pressure ulcer treatment and progress toward desired outcomes for two of three patients P# (P#1 and P#4) reviewed for altered skin conditions. The findings include: 1. Review of the plan of care for P #1 revealed an admission date on 4/15/22, with an admitting diagnosis of Alzheimer's disease Stage 1 pressure ulcer to sacrum. The wound care order dated 4/15/22, as follows: Cleanse with soap and water, rinse with water. Pat dry, apply Opti foam dressing. Wound care to be performed every three to five days. Assess wound for size, stage, drainage. Hospice nurse to assess wound every week. Review of the skilled nurse (SN) visit notes dated 4/14/22, 4/16, 4/18, 4/22 and 4/25, lacks the assessment of the wound. The interdisciplinary group (IDG) notes dated 4/20/22 and 5/4/22, lacked documentation of the assessment and the progress or lack of progress toward the desired outcomes/goals and the patient's response to wound care treatment. 2. Review of the plan of care for P #4 revealed an admission date on 4/26/22, with an admitting diagnosis of respiratory failure and end stage renal failure. Review of the plan of care dated 4/26/2022, revealed a diagnosis of stage 2 wound around the anus and on the labia. The wound care order dated 4/26/22, as follows: cleanse wound with wound cleanser, pat dry, place barrier cream on the wounds as needed. The IDG notes dated 5/4/22, lacked documentation of the progress or lack of progress toward the desired outcomes/goals and the patient's response to wound care treatment. During a record review meeting on 5/11/22, at 10:00 p. m., the Administrator and Director of Nursing (DON) stated, the all visit notes are reviewed during IDG meetings, but IDG notes lacked documentation of updated status/assessment, intervention, and progress of patient's wounds and its complications.

Based on clinical record review and staff interview, it was determined the Interdisciplinary team (IDT) failed to ensure the plan of care reflected the specific problems identified in the assessments, goals, interventions, and services necessary to meet the assessed needs of three of sixteen patients P# (P#3, P#4 and P#14) who were current hospice beneficiaries. The findings include: 1. Review of the plan of care for P #4 revealed an admission date on 4/26/22, with an admitting diagnosis of end stage chronic renal failure with indwelling Foley catheter and requires the skilled nurse (SN) to measure output every shift, empty Foley catheter, measure and document urinary output every shift. The SN note dated 4/26/22, the SN documents Foley draining at bedside with clear urine. However, review of the plan of care dated 4/26/22, lacks specific orders to change Foley catheter; size of the catheter to be inserted, the size of the balloon, the type and amount of solution to be instill into the balloon. The plan of care dated 4/26/22, lacks specific orders for Foley catheter care. 2. Review of the plan of care for patient #3 revealed an admission date of 4/21/22, with an admitting diagnosis of Alzheimer's disease and admitted with Percutaneous Endoscopic Gastrostomy (PEG) tube for enteral feeding and medications. However, review of the plan of care dated 4/21/22 lacks specific orders for PEG tube assessment and treatment to identify complications of the PEG tube and infections at the PEG tube insertion site. The plan of care dated 4/21/22 lacks specific orders for PEG tube care. 3. Review of the plan of care for patient #14 revealed an admission date of 6/8/21, with an admitting diagnosis of chronic obstructive disease and hypertension and Foley catheter orders as follow: Indwelling catheter with 16 Fr Foley catheter with 10 cc balloon. Change as needed. However, the Foley catheter order lacks specific steps to insert the Foley, type and amount of solution to inflate the balloon. Review of the plan of care dated 6/8/21 lacks complete Foley catheter order for the patient. During a record review meeting on 5/11/22, at 11:00 a.m., the DON and the Administrator verbalized the plan of care lacks orders for PEG tube care and lack complete order for Foley catheter.